Healthcare Provider Details

I. General information

NPI: 1639421365
Provider Name (Legal Business Name): FORDLAND CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11863 STATE HIGHWAY 13
KIMBERLING CITY MO
65686
US

IV. Provider business mailing address

1059 BARTON DR
FORDLAND MO
65652-7350
US

V. Phone/Fax

Practice location:
  • Phone: 417-739-1995
  • Fax:
Mailing address:
  • Phone: 417-767-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number26-1102
License Number StateMO

VIII. Authorized Official

Name: ROBERT MARSH
Title or Position: EXECUTIVE DIRECTOR
Credential: FNP
Phone: 417-767-2273